Disclaimer: This is my personal opinion and I hope we can agree to disagree if need be. If you are a perfect nurse, please do not read.
I have seen many threads on AN about false documentation and while most replies to these threads have been helpful many members feel the need to judge the OP for false documentation.
In my opinion, many floor nurses are guilty of false documentation, so what gives some of you the audacity to judge and berate another nurse.
How many times have you given a medication outside of that "one hour" window but charted it was given on time?
How many times have you documented your assessment at the time it was supposed to be done, when in reality it was done much later or even much earlier.
For my LTC, nurses are you 100 percent positive that your 20-60 residents were turned and repositioned every 2 hours, or that each one of them was toileted every two hours? Yet you will still initial those two initials in that square box.
When I was a nursing student I would often floor nurses "magically" come up with a patients weight, vital sign, or blood sugar and document, knowing that it was NEVER done. I was so quick to judge as a student and thought their license should be taken right away. After working as a nurse, I realized that while I don't condone that behavior I understand it.
If you answered NEVER to all my questions you are either a super nurse or either you work in a place that have perfect staffing, perfect patients, and perfect coworkers.
The purpose of this thread was for us to sit here and evaluate ourselves before we judge someone for false documentation.
I'm not talking about the nurse that is clearly negligent, lazy, and etc. I'm talking about the nurse like myself who provides competent and quality care to patients but faced with staffing issues that makes it nearly impossible to document every single thing as it is being done.
Unfortunately, some of us work in places where we no longer take care of patients but instead we are taking care of the higher ups in their effort to please the state.
Maybe if we can get rid of some of this customer service BS we can actually have more time for proper and precise documentation.
We are saving lives everyday. I rather give a calcium chew tablet 2 hours late than to ignore my patient that has CHF and having SOB.
So the moral of this story is that people in glass houses shouldn't throw stones.
For all of you nurses that never had to participate in "false documentation" I admire you, envy you and hope to be like you when I grow up.
Quote from grntea
why does everybody come to an and ***and moan about staffing in snfs and ltc and i don't ever see anyone saying what they did about this? is there anybody out there who has promulgated some sort of action to effect change in these situations? please, i wanna hear about it! everyone wants to hear about it!
you know, when you make out a variance report ("meds for south wing given two and one half hours late due to new admission assessment," "no weights done on first of the month, insufficient staff," "mds done 4 days early as i will be away on vacation and there is no one to cover me," "foley catheter care on five residents not done this shift, no time due to extended med pass.") it goes to your risk manager. if you are part of a corporate structure, it goes to the corporate risk manager.
risk managers get very cranky about this sort of thing, because they realize that when there are a lot of these, they indicate system-wide risk exposure, and that means money (fines, judgments), and that gets management's attention. if everyone does them, especially if you are in touch with colleagues from the other facilities in your network, you could <gasp> have an effect for the better.
if you are really ripped about the situation you're in, and you get no response from the risk manager maneuver, you could make anonymous reports to the state. but do something. act like professionals, the professional advocates you are. it's for the residents, see.
i have made many variance reports in my day for other nurses. it came to a point that i was making them on a daily basis and could not keep up with my work and i would leave work hours late doing these reports. i'm not sure if you've ever worked in ltc but this is where you will find most falsification of records.
greentea i have tried to do something about this. i have contacted the bon in my state with the concerns i had about staffing, and the mega med pass in ltc, and was turned away. the bon doesn't give a damn about nurses. the only time they want to protect patients is when something goes really wrong and a patient suffers. so much for prevention.
i have spoke to obudsman as i felt residents were not receiving proper care at one particular facility.
i have spoke with administrators, dons, and previous coworkers about my concerns at places i've work. it has gotten me no where. so yes, i do come on all nurses to b@#^$ and moan because no one else in the real world does anything.
so next time you accuse me or anyone else for not being professional or a patient advocate take the time to ask first. ummm, okay?
any more suggestions, honey?
Last edit by OnlybyHisgraceRN on Apr 26, '12